Breast lump (nandinii)


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Breast lump (nandinii)

  2. 2. Overview: Anatomy Breast Cancer -Definition -Classification -Symptoms -Diagnosis -Treatment Case Write up
  3. 3. Female Breast Anatomy  milk-producing glands situated on the front of the chest wall.  rest on the pectoralis major muscle - supported by Cooper’s ligaments.  Each breast contains 15-20 lobes arranged in a circular fashion.  The fat that covers the lobes gives the breast its size and shape.  Each lobe comprises many lobules, at the end of which are glands where milk is produced in response to hormones
  4. 4. Ducts Ducts carry Lobes, lobules, milk from bulbs and bulbs aretoward dark area Linked by a of skin in the network of thin center of the tubes (ducts) breast (areola) Ducts join togetherinto larger ducts ending Areola at the nipple, where milk is delivered 4
  5. 5. Lymphatic System  Lymph ducts: Drain fluid that carries white bloodLymph node Lymph duct cells (that fight disease) from the breast tissues into lymph nodes under the armpit and behind the breastbone  Lymph nodes: Filter harmful bacteria and play a key role inA network of vessels fighting off infection 5
  6. 6. Breast Cancer Cancer that forms in tissues of the breast,usually the ducts (tubes that carry milk tothe nipple) and lobules (glands thatmake milk). It occurs in both men andwomen, although male breast cancer israre. Breast cancer is second only to lungcancer as a cause of cancer deaths inAmerican women 6
  7. 7. EPIDEMIOLOGY: Estimated new cases and deaths from breast cancer in the United States in 2013: New cases: 232,340 (female); 2,240 (male) Deaths: 39,620 (female); 410 (male)(Source: National Cancer Institute)In MALAYSIA: National Cancer Registry (NCR 2006) reported 3,525 female breast cancer cases The most common diagnosed cancer in women & 29.9 % of all new cancers Overall Age-Standardised Incidence Rate: 39.3 per 100,000 population(Source: CPG)
  8. 8. ClassificationBreast Disease:Benign:-Low Risk lesion: Fibrocystic changes, Cyst, Fibroadenoma-Mod Risk lesion: Atypical ductal hyperplasia, Atypical lobular hyperplasia-High Risk lesion: LCIS, DCIS (premalignancy)Malignant- Invasive carcinoma: infiltrating ductal carcinoma, infiltrating lobular carcinoma- Inflammatory carcinoma
  9. 9. Type
  10. 10. Benign Conditions Fibrocystic changes: Lumpiness, thickening and swelling, often associated with a woman’s period Cysts: Fluid-filled lumps can range from very tiny to about the size of an egg Fibroadenomas: A solid, round, rubbery lump that moves under skin when touched, occuring most in young women
  11. 11. Normal Breast Breast profile A ducts B lobules C dilated section of duct to hold milk D nipple E fat F pectoralis major muscle G chest wall/rib cage Enlargement A normal duct cells B basement membrane (duct wall) C lumen (center of duct) 11Illustration © Mary K. Bryson
  12. 12. Ductal Carcinoma in situ (DCIS) Ductal cancer cells Normal ductal Carcinoma refers to any cell cancer that begins in the skin or other tissues that cover internal organs 12Illustration © Mary K. Bryson
  13. 13. Invasive Ductal Carcinoma (IDC – 80% of breast cancer) Ductal cancer cells breaking through the wall  The cancer has spread to the surrounding tissues 13Illustration © Mary K. Bryson
  14. 14. Range of Ductal Carcinoma in situ Illustration © Mary K. Bryson 14
  15. 15. Invasive Lobular Carcinoma (ILC) Lobular cancer cells breaking through the wall 15Illustration © Mary K. Bryson
  16. 16. RISK FACTOR
  17. 17. Signs and SymptomsMost common:lump orthickening inbreast. OftenpainlessDischarge Redness or pittingor of skin over thebleeding breast, like the skin of an orange Change in size or contours of Change in color breast or appearance 17 of areola
  19. 19. STAGINGTUMOR NODES METASTATICTx : could not assessed • Nx : could not assessed Mx : could not assessedT0 : no evidence of primary N0 : no regional lymph nodes M0 : no distant metastatictumor metastaticT1s : carcinoma in situ N1 : movable ipsilateral M1 : distant metastatic axillary lymph nodesT1 : < 2 cm N2 : fixed ipsilateral lymph nodesT2 : 2-5 cm N3 : ipsilateral internal mammary lymph nodesT3 : > 5 cmT4 : extension to chest wall orskin Staging 0 Ca in situ 1 T1 without nodes or mets 2 T1-2 + N1 or T3+N0 3 T1-4, N2-3 4 M1
  21. 21. MANAGEMENT(Algorithm for operable breast cancer)
  22. 22. MANAGEMENT(Algorithm for locally advanced breast cancer)
  23. 23. CASE WRITE UP
  24. 24. E, a 49 years old Siamese femalewas admitted electively toHospital Tuanku Fauziah on 2ndMarch 2013 for swelling of leftbreast associated with pain for 2weeks of duration.
  25. 25. HISTORY OF PRESENTING ILLNESS Left sided breast lump since 2010 MVA. Initially size of lump was the size of a 1 cent coin  increasing in size for the past few months to a 10 cent coin. Previously, non -tender on palpation till 2 weeks ago No discharge flowing from nipples No skin changes involved Claims occasional pain on sternal edge that radiates to back since breast lump present Loss of appetite for 1 month of duration
  26. 26. HISTORY OF PRESENTING ILLNESS Otherwise:-no clear loss of weight,-no shortness of breath during exertion or resting,-no bone pain, no fever, no upper respiratory tract symptoms,-no abdominal pain-no altered bowel habit No history of any breast disease prior to this. On follow up with KK Kodiang since 2010. Investigations carried out and patient was admitted electively for surgical intervention.
  27. 27. PAST MEDICAL HISTORY1. Bronchial Asthma- On MDI Salbutamol- MDI Betamethasone 2. Acute gastritisDone oesophagogastroduodenoscopy (OGDS) in 2009Diagnosed to have: Gastritis, Helicobacter pylori negative
  28. 28. PAST HOSPITAL ADMISSION -History of lower segment caesarean section (LSCS) done twice -History of appendectomy done -History of intestinal obstruction secondary to adhesion resolved with conservative care (2009) -History of motor vehicle accident with fracture on upper limb (2010)
  29. 29. FAMILY HISTORY No history of breast cancer or any other cancer running in the family No family member or DM, HPT, IHD
  30. 30. SOCIAL HISTORY 4th child from 5 siblings Patient is married with 2 children. Nonsmoker and non-alcoholic. Allergic to seafood.
  31. 31. PRESENT STATUS (03/03/2013: 8.00 pm) Vital signs Conscious level : Alert and conscious HR : 82x/min RR: 18x/min BP: 125/96 mmHg Temperature : 370C
  32. 32. GENERAL STATUS Head: No abnormality observed Neck: No increased JVP, No enlarged lymph nodes Thorax: Double rhythm no murmur. Vesicular breath sound without added sounds Breast : View localized status Abdomen: Surgical scar seen. Abdomen soft nontender Upper limb: No abnormalities Lower limb: No abnormalities
  33. 33. Localized Status Symmetrical   -Size Both breasts are symmetrical in size. -Shape Same shape of breast: Round with no -Position visible lumps seen Skin No visible skin abnormalities. No nodules No ulceration & fungation No texture difference between breast No puckering/dimpling No engorged veins No skin discoloration Nipples & Areolae Nipples present at both sides. Not retracted/ destroyed No accessory nipples Nipples dark brown in color Central in position Areolae smooth with nipple protruded out in the middle No discharge seen Hands by side / Lymph node enlargement not visible Hands slowly raised above head No distended veins No muscle wasting Hand pressed hips No tethering to the skin Unsure if fixated to underlying muscles
  34. 34. LOCALIZED STATUS Lump   -Temperature Warm -Tenderness Present on left breast -Site Left upper outer (towards the medial -Size line/border upper and lower) quadrant -Shape 1.5cm x 1.5cm -Surface Round -Margin Smooth -Consistency Well demarcated -Relation to the skin Hard -Relation to underlying muscle Mobile Not fixated Nipple   -Retracted nipple Nipple not retracted after release -Feel breast deep to the nipple Could feel the presence of lump -Press for discharge   -Appearance None -Character None -Color None Axilla & cervical lymph nodes   -Site Not enlarged -Surface - -Consistency - -Tenderness - -Conglumeration -
  35. 35. INVESTIGATIONS FINDINGS FROM PREVIOUS INVESTIGATIONS:  Mammography (June 2012)  Left sided breast cyst  Fine Needle Aspiration Cytology ( 14/02/2013)  Atypical suspicious of malignancy (C4 = cells suspicious but probably malignant) LAB INVESTIGATIONS  Full blood count  Renal profile  Liver function test  Chest radiograph  Electrocardiogram Histopathology examination
  36. 36. REVIEW OF INVESTIGATIONS Full blood count, Renal profile & Liver Function test were mostly in normal range. No significant finding Chest X-ray : Shows mild cardiomegaly ECG: Sinus rhythm. No significant changes
  37. 37. Chest X-ray
  38. 38. DIAGNOSIS: Breast carcinoma Fibroadenoma Fibrocystic Cyst WORKING DIAGNOSIS: Breast carcinoma Stage 1 (T1N0M0)
  39. 39. PLAN Wide local excision of left breast lump Vital signs monitoring Review investigations For anesthesiology to review for general anesthesia Keep nil by mouth starting from 12 midnight Intra venous drip 4 pint – 2 pint Normal Saline and 2 pint Dextrose 5%
  40. 40. POST OPERATION ASSESSMENT PRESENT STATUS (04-03-2013: 9.30 pm)Vital Signs:Conscious level : Alert and consciousHR : 72x/minRR: 16x/minBP: 122/73 mmHgTemperature : 370CSubjective:Patient complained of pain at the operation site. Pain score 3/10Patient vomited 2 episodes.No fever.Objective:Operation site bandage not soaked.Operation site slightly inflamed. But no signs of pus or active infection.
  41. 41. Assessment:8 hours post wide local excision for Left breast atypia.To give analgesic to ease pain.To give antiemetic for vomiting. Plan:Tablet Paracetamol 1gm QIDCapsule Tramal 50mg TDSTablet Maxolon 10mg Stat & PRNIntra venous drip 4 pint – 2 pint Normal Saline and 2 pint Dextrose 5%Continue vital sign monitoring.To inform if wound soaked